INCIDENT REPORT FORM



Date:

CONFIDENTIAL

____________________ LOS ANGELES UNIFIED SCHOOL DISTRICT ____________________

Time of Call: LOCAL DISTRICT 8 FAX

_______________ OPERATIONS (310) 817-1305

INCIDENT REPORT FORM

NAME/POSITION OF CALLER:

SCHOOL:

LOCATION OF INCIDENT: School phone: _____ EXT:

DATE AND TIME OF INCIDENT/ALLEGATION: _____ ______

1) VICTIM – Name/DOB: GRADE:

Injuries: _ _____

2) VICTIM – Name /DOB: ____ GRADE: ___ _____

Injuries:

DESCRIPTION OF INCIDENT: _

_______________________

SUSPECT(S): _____

SCHOOL ACTION(S) TAKEN:

REPORTED TO/SPOKE TO:

|Office/Unit Contacted |Person Taking Report |

|Local Police Agency | Badge No. |

|School Police – (213) 625-6631 | Badge No. |

|LAPD Child Abuse Unit - (213) 485-4700 | Badge No. |

|District 8 Operations – (310) 354-3413 | |

|Staff Relations – (310) 354-3412 | |

|District Crisis Team – (323) 754-2856 | |

|School Mental Health – (323) 750-5167 | |

|Nursing – (310) 354-3442 | |

|Environ. Health and Safety – (213) 241-3199 | |

|Food Services – (310) 354-3510 | |

|Complex Project Manager | |

|Maintenance & Operations (213) 792-5226 | |

|Sexual Harassment/Gender Equity (213) 241-7682 | |

|Transportation/Main Branch – (310) 515-3132 | |

|Youth Relations – (213) 745-1990 | |

|Neighboring Schools (if applicable) | |

|CSSA Report completed (if applicable) |Date: _________ CSSA#________________ |

OTHER CONTACTS WHEN APPROPRIATE:

FOLLOW-UP ON STUDENT(S)/ STAFF MEMBER(S) CONDITION (if applicable):

ADMINISTRATIVE FOLLOW-THROUGH:

DISTRICT 8 ACTION(S)(if applicable):

HANDLED BY:

(District Administrator) DATE

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